Question 16

College answer

The role of rigid bronchoscopy was not listed as an option in many candidates' answers, and there was also a lack of consideration for the different sided DLTs for several candidates. The clinical scenario presented was urgent and many candidates listed investigations which would have led to patient detriment e.g. MRI. Many candidates answered part b) with the management of coagulopathy when specific management of an isolated bleeding site was required. Clinical management and the answers in the part 2 CICM exam often require context, and this is no different in the vivas and clinical cases, and there are further comments to  demonstrate this later in the report.

Discussion

Quite right, to send the patient choking on blood into the MRI scanner should be viewed as a huge blunder of airway etiquette, and would have led to some low marks in this SAQ. Some may consider this as a critical failure point, i.e. where the answer is dangerous in some fundamental way, and should not pass even though the rest of the points mentioned are technically valid. 

a) Investigations:

b) Management options:

1) Achieve lung isolation

• Intubate the patient with a large-bore endotracheal tube to permit bronchoscopy
  • And position the patient in a lateral position with the bleeding lung dependent
• Or: introduce a bronchial blocker and inflate the balloon in the main bronchus of the affected lung
• Or: intubate the patient with a double-lumen endotracheal tube
  • For a bleed originating in the left main bronchus, a right-sided DLT is called for, as a left-sided DLF would not permit surgical or bronchoscopic access
  • For any other site of bleeding a left-sided DLT would be appropriate and much easier to place
  • Some authors argue that these devices are not useful because the small aperture of each lumen does not allow the passage of a "proper" bronchoscope, of the sort that has ample instrument or suction ports.

2) Trial conservative management: 

• Nebulised tranexamic acid 
• Nebulised adrenaline
• Ice saline lavage

3) Interventional bronchoscopy techniques

• Adrenaline injections
• Various gels, foams, sealants (including thrombin slurry)
• Temporary silicone plugs  
• Temporary bronchial stents
• Nd:YAG laser
• N-butyl cyanoacrylate glue

4) Rigid bronchoscopy techniques 

• Argon plasma coagulation
• Electrocautery
• The placement of larger stents
• The retrieval of larger clots

5) Interventional radiology

• Bronchial artery embolisation (coils, foam, glue, PVC particles)

6) Surgery is the last option:

• Lobectomy and pneumonectomy are often required
• The only option for pulmonary arterial or venous bleeding, and probably the preferred option for malignancies and large abscesses.